Haji Kavi, Haji Darsim, Canty David J, Royse Alistair G, Green Cameron, Royse Colin F
Department of the Intensive Care Unit, Frankton Hospital, PO Box 52, Frankston, VIC, 3199, Australia.
Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia.
Crit Ultrasound J. 2018 Jul 4;10(1):13. doi: 10.1186/s13089-018-0096-1.
Failed extubation from mechanical ventilation in critically ill patients is multifactorial, complex and not well understood. We aimed to identify whether combined transthoracic echocardiography, lung and diaphragmatic ultrasound can predict extubation failure in critically ill patients.
Fifty-three participants who were intubated > 48 h and deemed by the treating intensivist ready for extubation underwent a 60-min pre-extubation weaning trial (pressure support ≤ 10 cmHO and positive end expiratory pressure 5 cmHO). Prior to extubation, data collected included ultrasound assessment of left ventricular ejection fraction, left atrial area, early diastolic trans-mitral flow velocity wave (E), early diastolic trans-mitral flow velocity wave/late diastolic trans-mitral flow velocity wave (E/A), early diastolic trans-mitral flow velocity wave/early diastolic mitral annulus velocity (E/E'), interatrial septal motion, lung loss of aeration score and diaphragm movement. At the end of the weaning trial, the rapid shallow breathing index and serum B-type natriuretic peptide concentration were measured. Success and failure of weaning was assessed by defined criteria. Decision to extubate was at the discretion of the treating intensivist. Failure of extubation was defined as re-intubation, non-invasive ventilation or death within 48 h after extubation. Of 53 extubated participants, 11 failed extubation. Failed extubation was associated with diabetes, ischaemic heart disease, higher E/E' (OR 1.27, 95% CI 1.05-1.54), left atrial area (OR 1.14, CI 1.02-1.28), fixed rightward curvature of the interatrial septum (OR 12.95, CI 2.73-61.41), and higher loss of aeration score of anterior and lateral regions of the lungs (OR 1.41, CI 1.01-1.82).
Failed extubation in mechanically ventilated patients is more prevalent if markers of left ventricular diastolic dysfunction and loss of lung aeration are present.
重症患者机械通气撤机失败是多因素导致的，情况复杂且尚未被充分理解。我们旨在确定经胸超声心动图、肺部和膈肌超声联合检查能否预测重症患者的撤机失败。
53名插管时间超过48小时且被主治重症监护医生认为已准备好撤机的参与者接受了为期60分钟的撤机前撤机试验（压力支持≤10cmH₂O，呼气末正压5cmH₂O）。在撤机前，收集的数据包括超声评估左心室射血分数、左心房面积、舒张早期二尖瓣跨瓣血流速度波（E）、舒张早期二尖瓣跨瓣血流速度波/舒张晚期二尖瓣跨瓣血流速度波（E/A）、舒张早期二尖瓣跨瓣血流速度波/舒张早期二尖瓣环速度（E/E'）、房间隔运动、肺通气丧失评分和膈肌运动。在撤机试验结束时，测量快速浅呼吸指数和血清B型利钠肽浓度。根据既定标准评估撤机成功与失败情况。是否撤机由主治重症监护医生自行决定。撤机失败定义为撤机后48小时内再次插管、无创通气或死亡。在53名撤机的参与者中，11人撤机失败。撤机失败与糖尿病、缺血性心脏病、较高的E/E'（比值比1.27，95%置信区间1.05 - 1.54）、左心房面积（比值比1.14，置信区间1.02 - 1.28）、房间隔固定向右弯曲（比值比12.95，置信区间2.73 - 61.41）以及肺前侧和外侧区域较高的通气丧失评分（比值比1.41，置信区间1.01 - 1.82）相关。
如果存在左心室舒张功能障碍和肺通气丧失的标志物，机械通气患者撤机失败更为常见。
